fter a heavy air attack in a remoteoverseas location, military ser-vicemen are waiting for immedi-

ate hospitalization. One is experiencinginternal hemorrhaging, another hascrushed bone fragments causing excruci-ating pain, and still others are experienc-ing nausea from unknown chemicalwarfare. The nearest hospital is more than1,500 miles away.Enter the world of

telemedicine. A “Star Trek” future ofmedical care delivery, which has arrivedon U.S. Air Force bases and otherDepartment of Defense divisions, is put touse. High-tech telecommunications fordata transfer and combat control, whichhave led the way for high-tech medicalsolutions, become lifesavers.

With a basic PC, a phone line,and a modem, simple store and forward

capabilities can be instituted to talk tospecialists on the other side of the ocean.For a modest five figure investment, add avideo camera and high bandwidth withsupporting robotics controls to create real-time interactive patient management.

This reality-based approach tomedicine has not yet actually seen abattlefield situation. However, it hasentered the lives of thousands of

AIR FORCEÕS REALTIME MEDICINEBy Dawn M. Yankeelov

During the past three years, the Air Force has developed a telemedicine capability.Today, service personnel and their families from Alaska to Bosnia

are benefiting—and the process is just beginning.

A

servicemen stationed on Air Forcebases in the United StatesTelemedicinetraining also began in October 1996 inBosnia and Saudi Arabia to serve troopsalready there.

The Department of Defensefirst cataloged success with telemedi-cine in 1993 when a serviceman’ssevere skin rash wasdiagnosed fromSomalia. Doctors were baffled and usedtelepathology to transmit a mic-roscopic image of the rash to a derm-atologist at the Walter Reed ArmyMedical Hospital in Washington, D.C.A microscope in Somalia was operatedvia computer tomake diagnosis andtreatment possible.

“Air Force medical serviceshave been involved for the last 3 1/2years in Department of Defense dem-onstrations, trying t o prove or deter-mine how best to utilize communica-tions for better patient management,”Dr. Michael James Benge, Director ofStrategic Man- agement in the U.S. AirForce Surgeon General’s Office andoverseer of Air Force medical oper-ations,said. “It’s so dependent on imagecapture. And in the early analysis, it’svery profitable for all involved.

Through 2001, telemedicinetraining will be completed for combat

readiness, according to Dr.Benge.On baseseverywhere in the U.S., military physicianswill move to eliminate the need for sub-specialists in every location. “This willdownsize the number of people andequipment required, avoid costly travel forpatients to the large medical centers, andsave space ultimately,” Dr. Benge said.

For example, digital radiologyeliminates the need for expensive X-rayfilm to be stored. Dr. Benge explained,“Tons and tons of equipment, chemicalsand water could be eliminated for thisspecialty. The space needed to store X-rayfilm could be reallocated.”

The environment benefits directlyjust in the use of telemedicine in radiologyalone,because the U.S. Air Force caneliminate the requirements to reclaimsilver ions from water after developingfilm. It’s a near instantaneous payoff, Dr.Benge added.

Telemedicine in the Air Forcegenerally uses an interactive video systemintegrated with biomedical telemetry,except in areas where high bandwidth iscost prohibitive. Store and forwardsystems, that use “snapshots” instead ofreal-time television, work as well. Theyallow a physician at a specialty medicalcomplex or teaching hospital to examineand treat patients at multiple

satellite locations, such as rural hospitalsand clinics.

Integrated into the video system,and based on the requirements of theremote medical facility, are a number ofdiagnostic devices. The remotely con-trolled examination camera has a power-ful zoom-focus capability that allows adermatologist to examine small details ofa patient’s skin. An electronic stethoscopepermits a cardiologist to do a completecardiological examination. Specificcamera adapters and resolution capabili-ties enhanced by remote controlled opticsprovides an ophthalmologist a clear viewof the retina at the referring site. A

specialist can review any type of X-rayexamination, including an MRI, CAT scanor ultrasound. Investments in equipmentsetup range from $15,000 for storage andforward to $200,000 per site for probesand live television feeds.

Telemedicine was unveiled forbroad military use in June 1995, when thePentagon conducted a tri-service exhibitfeaturing live demonstrations oftelemedicine in support of day-to-dayoperations. At that time, then Secretary ofDefense William J. Perry told the AirForce News Service, “Telemedicine isnot just a new use of old technologies. Itcombines cutting-edge telecommunica-

Telemedicine’s enormous potential in the battlefield is demonstrated by this exhibition, in which anattending physician assists a distant surgeon who uses electro-mechanical manipulators, lights andtelevision cameras to view the patient, communicate with the on-site physician and actually performsome of the surgical procedures.

SPOTLIGHTS

tions systems with specialized medical equip-ment to project medical care in real-timeanywhere in the world.”

During one international demonstra-tion, doctors at the exhibit consulted viasatellite with doctors at the Air Force’s 60thMedical Group Hospital at Zagreb, Croatia,about previous cases. Doctors also held liveteleconsultations with medical units in Haiti andI Macedonia by satellite.

TRICARE Southwest: An InternationalTelemedicine Network

The first successful wide-scaleprogram implemented in the Air Force wasdirected by Capt. Ken Bonner, now of MATMO(Medical Advanced Technology ManagementOffice). His success led to his current involve-ment with the efforts to set up telemedicine inRiyadh, Saudi Arabia, where about 7,000 U.S.troops reside. “The Air Force realizes that youhave to move information, not people. Thedelivery of quality health care is verbal, textualand image-based,” Capt. Bonner said.

The TRICARE SouthwestTelemedicine Pilot Project is an approvedDepartment of Defense, Health Affairs (MHSSProponent Committee), proof-of-conceptproject initiated in Region VI. The regioncovers Oklahoma, Arkansas and major portionsof Eastern Texas and Western Louisiana. TheDepartment of Defense medical plan in thisregion is centered around two military medicalcenters-Wilford Hall Medical Center andBrooke Army Medical Center. They provide

A corpsman examines battlefield casualties and prepares to administer first aid in this telemedicine simulation.His helmet-mounted television camera and voice communications link allow him to transmit real-time images ofthe wounds, plus his comments and questions, to a doctor located in a Mobile Medical Mentoring Vehicle, locatedseveral miles from the battle area. Thus, the corpsman does not have to make difficult medical decisions alone.

services to approximately 1 million people.Capt. Linda Eaton, now in charge of

the fully operational program that beganseveral years ago, outlined the followingprogram goals:

• To improve access and quality carea rural bases;

• To increase beneficiary andprovider satisfaction with health caredelivery;

• To prepare providers for support ofdeployed forces via teleconsulting;

• To improve and facilitate cross-service referrals;and

• To be cost-effective or cost-neutral.

“A paradigm shift must occurthrough telemedicine training. Physicians arenot up to speed on their thinking about itsbenefits, but through education the messageis getting out that this type of support is animportant tool,” Capt. Eaton said.

The plan is to have a telemedicinenetwork organized to function as a compre-hensive system for the whole region, creatinga “virtual health care delivery system.” Thenewly embraced technologies include digitalcompression, store and forward, automatedmedical records, video e-mail and computernetworks. OC-3, DS3, and T1 bandwidth ondemand technology, coupled with theDICOM standard for medical informationinterchange, supports the multimedia mixnecessary for gathering and analyzinginformation.

For example, doctor-to-doctorcontact includes the transmission ofmedical records, transmission of medicalimages, video consultations and rules-based messaging. Doctor-to-patientcontact includes remote patient monitor-ing, delivery of health information andvideo consultations.

Military treatment facilitiesinvolved with the TRICARE implementa-tion include Corpus Christi Naval Hospitalin Corpus Christi, Tex., Goodfellow Clinicin San Angelo, Tex., Dyess Hospital inAbilene, Tex., Ft. Polk Hospital inLeesville, La., and Laughlin Hospital inDel Rio, Tex. Between 50-100 patients permonth stand to be served by telemedicineat each facility. Full program implementa-tion is to occur in late 1997. “The patientsseem to accept the technology. In mostcases, they see a specialist on the screentalking with them and the attendingphysician,” Capt. Eaton said. “Downtimeand costly travel is avoided. A typicalspecialist may be booked two to fourweeks in advance. This changes the timeframe in favor of the patient.”

“All patients I’ve worked withthink it’s a great idea, “ Lt. Col. Dr. GaryGronseth, a Wilford Hall neurologist,

added. “The only difference is that youcan’t actually touch the patient.”

The teleradiology and thetelepathology system were the mostsupported at the program’s outset. AtWilford Hall, eight telemedicine stationshave been established. Brooke ArmyMedical Center has a central suite andtelemedicine sites in cardiology, dermatol-ogy, ophthalmology, surgery and pediat-rics. Other specialists who have conductedtelemedicine consultations from WilfordHall represented endocrinology, gastroen-terology, ophthalmology, rheumatologyand urology. When expanded to all theregion’s military installations, theTRICARE project could become thelargest telemedicine network

Air Force Surgeon General’s Office,Air Combat Command, Langley, VA

“Everyone thinks that thestandard “Star Trek” real -TV transmis-sion approach is the only way to go, butwe are using email and digital cameras todo telemedicine. With essential ISDNconnections, we use store and forwardcapabilities to get the job done,” Lt. Col.Dr. Hadley Reed of Air Combat Com-mand said.

Dr. Reed oversees a pilot projectbetween Offutt AFB in Nebraska andWhiteman AFB in Knonoster, Mo. “Weare trying to help smaller facilities, likeWhiteman, with low bandwidth toexamine snapshots and answer ques-tions,” Dr. Reed said. “You can’t make thephysician transmit. We haven’t gottenover that speed bump. Physicians are notused to using the technology. Our energyof activation needs to be here to achievetotal success. The next generation ofdoctors will be ready.”

The program’s first four monthsinvolved fewer than 50 patients butproved the system’s premises. Totalsavings can climb well into five-figuresums per specialty, according to militarymodels for Offutt AFB and WhitemanAFB.

Dr. Reed notes that telemedicine isparticularly useful for dermatologists andophthalmologists—an important point withthe emphasis on eyesight for Air Forcepilots, and the ongoing threat of chemicaland biological weapons in the Middle East.“You don’t need video of retinas or eardrums or skin rashes. Photos work. Listen-ing to a heartbeat can also be had by email.An audio clip, for example,” he said.

TELEMEDICINE ...Mental health patients can also

be evaluated through telemedicine. “In thepast, as much as three days would be lostto travel to see if a patient would requirehospitalization through a psychiatricevaluation,” Dr. Reed said.

Dr. Reed sees widespreadimplementation of telemedicine in theU.S. Air Force within 5-10 years. “Peopledo not realize that disease and non-battleinjuries are more of a concern in warfare.Telemedicine can give near instantaneoustracking of the health of a force, if usedefficiently.”

3rd Medical Group, Elmendorf AirForce Base, Anchorage, Alaska

In Alaska, telemedicine mayserve approximately 40 percent of thepopulation in the near future, since theDepartment of Defense administers thehealth care of active military, retiredmilitary and dependents through anintricate partnership. Capt. Greg D.Carson, clinical systems engineer fortelemedicine in Alaska, claims tremen-dous program success. “The reducedpatient travel to Elmendorf from fourother program nodes is particularlywelcomed based on the weather themilitary faces here, in addition to thedistances between medical clinics,” hepointed out.

The other Alaska sites involvedare Adak Clinic at Adak Naval Station,Kodiak Clinic at the U.S. Coast GuardStation in Kodiak, Eielson Clinic atEielson AFB, and Bassett Army Hospitalat Ft. Wainwright. Involved with the DoDhealthcare initiative in the winter wonder-land are Veterans Affairs and the IndianHealth Service.

Air evacuations, particularly inAlaska, often may be risky, delayingaccess to critical care or preventing italtogether. The state comprises 25 percentof all U.S. Iand acreage and covers thesame north-south distance as the entirelower 48 states. It presents a challenge toprovide specialty medical professionalsfrom the 3rd Medical Group to AdakClinic, at the Adak Naval Station some1,500 miles away. Located in the AleutianIslands, Adaks NAS is the most remotesite in the network. Meanwhile, the CoastGuard clinic on Kodiak Island is an airflight from Anchorage, subject to extremeweather conditions, and is a free-standingfamily practice clinic.

With dedicated data circuits (56Kbps), store and forward technology, and

video teleconferencing suites at the fiveprimary medical sites in Alaska, evenlong-distance physical therapy manipula-tion and teledentistry were introduced.Real-world use included an oral surgeonwanting the advice of an orthodontistbefore operating, a preoperative evalua-tion for wisdom teeth extraction and aperiodontic evaluation for gum diseaseand treatment. “Over the first ninemonths, 31 dental consults were per-formed, saving more than 190 days and$40,000 in travel expenses,” Col. FredNolan, Jr. said.

Equipment choices supported theuse of low bandwidth, since high band-width circuits at 1.54 mbps and ISDNwere not available. A pair of switched 56Kbps data circuits was installed at eachlocation. The CLI Eclipse 8100 Modelwas selected for video teleconferencing at15 frames per second with full duplexaudio. The need for store and forwardbecame apparent early in 1996, sosoftware and hardware under the nameMD/TV was selected. An object camerawas also available at all locations.

Col. Nolan reports that emer-gency orthopedic care has worked out, asin the case of a patient who had fallen onduty, fracturing his little finger. There wasa question handled via telemedicine as towhether surgery would be required. “Thehuman response to telemedicine in Alaskahas been very positive. Providers dodescribe the need to reach out and touchthe patient, but go on to state they puttheir hands in their pockets. The initialshyness disappears quickly and the face-to-face relationships become a strongpoint,” he said.

Overseas and BeyondWell into 1997, telemedicine will

become an integral part of the militarypresence overseas, starting in SaudiArabia. Next, up to nine clinics will beoutfitted in nearby Kuwait, Oman andBahrain, at a cost of $50,000 per installa-tion.

INMAR-SAT-based systems,which can be set up anywhere, willrepresent Phase II for DoD supporting theU.S. efforts in Bosnia. “People have notput telemedicine into enough peacetimecare yet. We need to get our people intousing this on a daytoday basis,” Dr.Benge, who oversees the ongoingtelemedicine launch in the U.S. Air Force,said. “Telemedicine is very glamorous,butit is still a concept trying to size itself andfind itself, in terms of applications.”